Design: Cross-sectional. Objective: Aim 1 was to preliminarily explore the contributions of the following factors to adherence to LBP practice guidelines using regression modeling: 1) the credential qualification of Mechanical Diagnosis and Therapy (MDT); 2) balance of biomedical and behavioral (i.e. biopsychosocial) oriented approach for low back pain (LBP); 3) demographics; 4) academic degree and 5) the attitude towards updating information for evidence-based clinical practice. Aim 2 was to investigate whether therapists credentialed in MDT (Cred.MDT) were more behavioral oriented and less biomedical oriented than general physical therapists. Summary of Background Data: LBP practice guidelines are not adhered to by every physical therapist. MDT is a behavioral modification approach. Thus, it was hypothesized that the Cred.MDT therapist was more behavioral oriented and more adherent to LBP practice guidelines compared with general physical therapists. Methods: One-hundred-twenty Cred.MDT therapists and 2000 general physical therapists in Japan were contacted. For regression modeling, the dependent variable was adherent to guidelines using a questionnaire with a vignette. Independent variables included balance of biomedical and behavioral perspectives for LBP using the Pain Attitudes and Beliefs Scale for Physiotherapist (PABS-PT), demographics, academic degree and the attitude towards updatinginformation for evidence-based clinical practice. The ratio of the two mean scores of the biomedical and behavioral subscales in the PABS-PT was compared between the Cred.MDT therapist group and the general physical therapists group. Results: Data of 46 general physical therapists and 44 Cred.MDT therapists were available. The Cred.MDT therapist group was significantly (P < 0.05) more behavioral oriented and more adherent to LBP practice guidelines compared with the general physical therapist group. The regression indicated significance of the two predictors of adherence to guidelines, Cred.MDT (β = 0.58, P < 0.001) and academic degree (β = 0.19, P = 0.03). Conclusions: Cred.MDT therapists are more guideline-consistent and have a more biopsychosocial treatment orientation than general physical therapists in Japan.
Low back pain (LBP) practice guidelines have been developed and disseminated to facilitate evidence-based clinical practice in primary care for LBP. Adherence to guidelines is useful to improve clinical outcomes with lower utilization of care and reduced cost [
Current guidelines reflect the biopsychosocial nature of non-specific LBP and suggest the importance of considering using a behavioral-oriented approach to manage LBP [
Mechanical Diagnosis and Therapy (MDT) or the McKenzie approach is one of the common approaches for LBP [
Ideally, all possible relevant variables should be included in a model which predicts adherence to LBP guidelines. However, a large sample would be required to undertake such an extensive study [
The purpose of this study was twofold. The primary purpose was to undertake a preliminary exploration of the contributions of the following factors to adherence to LBP practice guidelines: 1) credential MDT qualification status; 2) the balance between biomedical and behavioral perspectives during LBP management; 3) demographic factors; 4) the highest education level attained and 5) the attitude towards self-directed learning to facilitate evidence-based clinical practice. The secondary purpose was to investigate whether Cred.MDT therapists were more behavioral oriented and less biomedical oriented than general physical therapists.
This study included two groups of therapists who treated patients with LBP. One group consisted of the 120 Japanese physical therapists who had obtained the credential MDT qualification (Cred.MDT) at January 2013 (Cred.MDT therapist group). The other group consisted of physical therapists without credential MDT qualification who participated in the 49th Congress of the Japanese Physical Therapy Association in 2014, in which 8000 therapists participated (general physical therapist group).
Survey with voluntary response sampling was used in this study for both groups and data was collected anonymously. For the Cred.MDT therapist group, the sets of questionnaires were distributed via e-mail to the registered Cred.MDT therapists. The response was possible on the web for one month. An email reminder was not undertaken. For the general physical therapist group, 2000 surveys were distributed randomly by hand to the eligible physical therapists as it was expected that approximately 2000 therapists are interested or specialized in musculoskeletal physical therapy, considering 17.8% of the proportion of presentations regarding musculoskeletal physical therapy registered to all 895 presentations registered in the congress (unpublished data). The response was possible with the hard copy during the congress or on the web for one month.
Exclusion criteria were a participant with missing data. Ethical approval for the study was obtained from the Research Ethics Committee of the Society of Physical Therapy Science in Japan. The response to the survey was handled as the consent for their participation in this study.
Adherence to LBP practice guidelines was assessed using established three questions for a vignette of a patient with LBP [
This study used a translated version into Japanese of the Pain Attitudes and Beliefs Scale for Physiotherapist (PABS-PT) that was originally developed in 2003 by Ostelo et al. [
Demographic information was collected on participant’s gender and age. The highest education level attained was categorized into a 3-ordinal scale (1 = less than Bachelor degree, 2 = bachelor degree and 3 = post-graduate degree). The attitude of therapists towards self-directed learning to facilitate evidence-based clinical practice was examined in 1) the number of external seminar, such as study meetings, lectures, workshops and conferences per year; 2) the number of academic papers in Japanese read per month; and 3) the number of academic papers in English read per month.
Variables except adherence to LBP practice guidelines were substituted using the mode for missing data. The following three analyses were conducted.
While developing a model to identify promising variables that contributed to adherence to LBP practice guidelines, the three dichotomized variables of adherence to guidelines were summed and used as one dependent variable (ranging from 1 to 4), where greater values indicated greater adherent to LBP practice guidelines. Categorical multiple regression models were built with all 8 variables (1: general physical therapist {1} or Cred.MDT therapist {2}; 2: biomedical/behavioral ratio; 3: men {1} or women {2}; 4: age; 5: the highest education level attained {1 - 3}; 6: the number of participation in external seminar per year; 7: the number of academic papers in Japanese read per month; 8: the number of academic papers in English read per month).
In each of the three items of adherence to guidelines, the proportion of the guideline-inconsistent and guideline-consistent was compared between the general physical therapist group and Cred.MDT therapist group in order to further consider the difference in adherence to guidelines between the groups. Fisher’s exact test was conducted.
The biomedical/behavioral ratio was compared between the general physical therapist group and Cred.MDT therapist group in order to examine the difference in the attitude towards LBP management. Two-tailed independent sample t-test was used as normal distribution of data was confirmed with the Kolmogorov-Smirnov test.
All statistical analyses were performed with SPSS version 21.0 (IBM Corporation, New York, USA). The level of significance was set at P < 0.05.
Fifty-six Cred.MDT therapists and 53 general physical therapists participated in the study. However, eight Cred.MDT therapists and seven general physical therapists were excluded due to missing data of adherence to LBP practice guidelines. Therefore, response rate for available data was 36.6% and 2.3% in the Cred.MDT therapists group and the general physical therapist group, respectively.
The results of the regression indicated that the two variables explained 62.7% of the variance of adherence to LBP practice guidelines (R2 = 0.39, adjusted R2 = 0.33, F(9,80) = 5.76, P < 0.001). It was found that the Cred.MDT therapist significantly predicted adherence to LBP practice guidelines (β = 0.58, P < 0.001), as did the highest education level attained (β = 0.19, P = 0.03).
Of the variables examined, the presence of Cred.MDT was the primary contributor and the highest educational level was the secondary contributor to adherence to LBP practice guidelines. This study also revealed that the clinical practice of Cred.MDT therapists was more in line with LBP guidelines and that their practice was more biopsychosocial-orientated, as opposed to the general physical therapist group.
This study revealed that 74% of the general physical therapist group was guideline-consistent for activity, but only 57% and 20% of them were guideline-consistent for work and bed-rest, respectively. It is tempting to speculate that the general physical therapists group in our study were more motivated and inclined to practice evidence-based physical therapy than the majority of physical therapists in Japan considering the fact that we have sampled those who participated in the biggest national conference of physical therapy in Japan. Therefore, we would expect that the average adherence to LBP guidelines of the total population of physical therapy in Japan to be lower than the guideline-consistent values of 57% (work) and 20% (bed-rest) found in this study. Nevertheless, the three ratios of the general physical therapists who were consistent with guidelines seem to be lower than those of physical therapists in New Zealand (activity, 92.9% guideline-consistent; work, 95.3% guideline- consistent; bed-rest, 100% guideline-consistent) [
This study also revealed that neither demographics nor the magnitude of reading papers and attending outside seminars influenced adherence to LBP practice guidelines. However, it is considered that the magnitude of reading papers amongst Japanese therapists including MDT therapists would not be sufficient to keep abreast of
Variables | Cred.MDT therapist n = 44 | General physical therapists n = 46 |
---|---|---|
Adherence to low back pain practice guidelines | ||
Total score (range 1 - 4) | 3.4 (3.2 - 3.7) | 2.5 (2.3 - 2.7) |
Guideline-consistent in activity* | 42 [ | 34 [ |
Guideline-consistent in work* | 34 [ | 26 [ |
Guideline-consistent in bed rest* | 31 [ | 9 [ |
PABS-PT | ||
Biomedical/behavioral ratio† | 0.87 (0.81 - 0.93) | 1.19 (1.11 - 1.26) |
Demographics | ||
Men | 32 [ | 38 [ |
Age (years) | 37.4 (35.0 - 39.8) | 34.5 (32.5 - 36.6) |
The highest education level attained | ||
Less than Bachelor degree | 27 [ | 23 [ |
Bachelor degree | 13 [ | 13 [ |
Post-graduate degree | 4 [ | 10 [ |
Attitude of therapists towards self-directed learning to facilitate evidence-based clinical practice | ||
The number of participation in external seminar per year | 7.5 (5.0 - 9.9) | 5.8 (3.9 - 7.6) |
The number of academic papers in Japanese read per month | 3.7 (2.4 - 5.0) | 3.0 (2.2 - 3.9) |
The number of academic papers in English read per month | 1.6 (0.2 - 2.9) | 0.9 (0.2 - 1.6) |
Abbreviations: Cred.MDT, credentialed in Mechanical Diagnosis and Therapy; PABS-PT, the 19-item Pain Attitudes and Beliefs Scale for Physiotherapist. Values are presented as mean (95% confidence interval of lower bound-upper bound), or numbers [%]. *Fisher’s exact test demonstrated a statistical significant difference in the ratio of “guideline-inconsistent” and “guideline-consistent” between the groups in activity (P = 0.007), work (P = 0.046) and bed rest (P < 0.001). †Independent sample t-test demonstrated a statistical significant difference (P < 0.001) between the groups.
the updates in evidence-based physiotherapy, which may result in very low usage of the Physiotherapy Evidence Database in Japan [
The potential contributors to adherence to LBP practice guidelines include the Cred.MDT and the highest education level attained. These findings are not surprising considering that the educational curriculum to obtain the Cred.MDT license is standardized throughout the world, which is a postgraduate education level. Therefore, we contend that the Cred.MDT therapist has similar knowledge about musculoskeletal disorders compared to those with postgraduate degree. Holders of higher academic qualifications are expected to have more knowledge about evidence-based clinical practice than holders of lower academic qualifications.
The Cred.MDT therapist group had a lower biomedical/behavioral ratio than the general physical therapist group. The upper limit of 95% CI was <1 in the Cred.MDT group while the lower limit of 95% CI was >1 in the general physical therapist group. These indicate that the Cred.MDT therapists have more biopsychosocial treatment orientation than biomedical treatment orientation while the general physical therapists have more biomedical treatment orientation than bio-psycho-social treatment orientation. These findings may be attributed to at least two reasons. First, MDT is a treatment-based approach where decision making for management strategies is based on patient’s symptom responses to mechanical loading [
This study indicated that the Cred.MDT therapists were more biopsychosocial treatment orientated than biomedical treatment orientated but it is uncertain whether learning MDT will change therapist’s treatment approach from a biomedical to a biopsychosocial perspective. It would be interesting to investigate the change in therapist’s treatment perspective in response to MDT education in a prospective study to determine the benefit of learning MDT for disseminating evidence-based clinical practice for LBP not only in Japan but also countries with limited evidence-based clinical practice in the management of LBP.
One of the limitations in this study is our small sample size in particular for the general physical therapists group. We anticipated a 10% response from the general physical therapist group (i.e. 200 data samples) while 92 data samples were required to adequately reflect a target sample of 2000 general physical therapists (95% confidence level and 10% margin of error). However, the actual response ratio was lower than our expectation. Furthermore, this study used voluntary response sampling, which is a limitation by ethical concerns. Thus, it is likely that the general physical therapists group was not sufficiently represented. However, it is possible that the low response in the general physical therapist group indicates the lack of opportunities or motivation to consider adherence to LBP practice guidelines or biopsychosocial perspectives for LBP management. In addition, there were more samples (N = 90) than the minimum sample size to run the multiple regression analysis of this study, which was estimated by G*Power 3 [
The authors wish to acknowledge cooperators for processing cross-cultural adaptation of the scale for the adherent to low back pain practice guidelines [
An English original questionnaire is available in [
以下のケースに対して、あなたはどのように対応しますか?以下の3つの質問全てに対して、最も適切なものに○をつけてください。
28歳、女性。腰痛既往歴無し。3週間前に仕事で10kgの箱を持ち上げたときから腰痛あり。患者は病院のカフェテリアの仕事をこなす事ができず、腰痛発症以来仕事を休んでいる。痛みで動けないと感じていて、仕事への復帰も不安に思っている。仕事内容は様々ではあるが、身体的な負担になるものはほとんどない。患者はフルタイムで勤務しており、家には頼れる人がいない。患者は、腰痛の痛みで我慢できなくまるまで、10分ほど座位を保持出来き、100メートルほど歩行することが出来る。夜は眠る事ができるが、朝起きた際には腰部のこわばりを感じ、10分ほどそれが継続する。これまで、外傷や重度の疾患既往は無い。痛みは腰部に限定しており、放散痛は無い。身体的検査では、明らかな前屈の制限と左腰部の圧痛がある。神経的な検査は正常で、SLR90°を超えても痛みが増加しない。その他の問診・身体的検査でも特記すべき点はなく、腰痛が始まってから医療従事者を訪れたことは無い。
A. 活動:痛みが改善するまで、私は患者に以下のことを勧める。
1. 全ての身体的活動を制限する
2. 軽度な活動以外を制限する
3. 中程度の活動まで制限する
4. 痛みを伴う活動のみ制限する
5. 全ての活動を制限しない
B. 仕事:痛みが改善するまで、私は患者に以下のことを勧める。
1. 仕事を休む
2. パートタイムで軽い仕事を行う
3. フルタイムで軽い仕事を行う
4. パートタイムで通常通りの仕事を行う
5. フルタイムで通常通りの仕事を行う
C. 寝て休む:私は患者に以下のことを薦める。
1. 痛みが完全に消失するまで寝て休む
2. 痛みがかなり改善するまで、寝て休む
3. 痛みが重度の時のみ、寝て休む
4. 可能な限り寝て休むのを避ける
5. 寝て休むのを完全に避ける
※ガイドライン準拠は、質問Aでは4以上、質問Bでは3以上、質問Cでは4以上とする。
An English original questionnaire is available in [
このアンケートの目的は、あなたが最も一般的なタイプの腰痛に対して、どのようにどの様にアプローチをしているかを知ることです。ここで言う腰痛とは、神経根症候群、馬尾症候群、骨折、感染症、炎症型の症例、腫瘍、転移などが原因で起こったものではないものとします。このアンケートはあなたの腰痛に関する知識を問うものではなく、単純に、あなたが実際どのようにアプローチしているかを知るためのものです。他人の意見や一般的な考え方ではなく、あくまであなた個人の意見をお聞かせ下さい。